Eric R. Wright

Social Networks and Patterns of Use Among the Poor with Mental Health Problems in Puerto Rico

OBJECTIVES This study uses the recently developed Network-Episode Model (NEM) to examine the nature and correlates of utilization among Puerto Ricans reporting mental health problems. The NEM highlights two issues: (1) examining the patterns or combinations of lay and formal use that individuals employ and (2) reformulating how the availability and content of social networks influences patterns of care. METHODS Using data from the 1989 Mental Health Care Utilization Among Puerto Ricans Study (probability sample of 1,777 individuals living in low-income areas of the island), the authors focus on the patterns and correlates of use for 365 Puerto Ricans reporting service use for mental health problems in the previous year. RESULTS A combination of clustering and multinomial logit techniques indicates that there are six unique care patterns. Two patterns include the use of mental health providers and are associated with different contingencies. CONCLUSIONS In general, patterns of use are shaped by age, education, gender, and illness severity. Larger, more supportive networks decrease the use of patterns of care that include formal health care providers, and decrease direct entry into the mental health sector. These results are in line with NEMs predictions for lower class populations and help clarify inconsistencies in previous research on social networks. The implications of this perspective for health services research and treatment are discussed.

Sexual Identity Distress, Social Support, and the Health of Gay, Lesbian, and Bisexual Youth

SUMMARY Sex researchers and mental health clinicians have long recognized that the stigma surrounding homosexuality plays an important role in shaping the social psychological adjustment of gay, lesbian, and bisexual (g/l/b) people. In recent years, researchers have suggested that sexual identity-related distress may influence the physical health status of g/l/b people, primarily because of the ways these self-related feelings and beliefs impact patterns of health-related behavior. This study examines the influence of sexual identity distress and social support on g/l/b youths drug and alcohol use, psychological distress, and risky sexual behavior. The data come from a services research demonstration program conducted at the Indiana Youth Group, Inc., a g/l/b youth development agency based in Indianapolis, Indiana. Results indicate that sexual identity distress is strongly associated with psychological distress, less frequent use of alcohol, and using fewer types of illegal drugs. Being out to more people in ones support network, however, attenuates the severity of youths sexual identity-related distress. Youth who report more support ties to g/l/b people indicate engaging in more frequent risky sexual behavior. The implications of these findings for theories of g/l/b youths sexual identity development are discussed.

Gay-related Development, Early Abuse and Adult Health Outcomes Among Gay Males

This study examined relationships between timing of gay-related developmental milestones, early abuse, and emergence of poor health outcomes in adulthood among 1,383 gay/bisexual men in the Urban Men’s Health Study. Latent Profile Analysis grouped participants as developing early, middle or late based on the achievement of four phenomena including age of first awareness of same-sex sexual attractions and disclosure of sexual orientation. Participants who developed early were more likely, compared to others, to experience forced sex and gay-related harassment before adulthood. They were more likely to be HIV seropositive and experience gay-related victimization, partner abuse and depression during adulthood. Early forced-sex, gay-related harassment and physical abuse were associated with several negative health outcomes in adulthood including HIV infection, partner abuse, and depression. This analysis suggests that the experience of homophobic attacks against young gay/bisexual male youth helps to explain heightened rates of serious health problems among adult gay men.

Medical Sociology and the Study of Severe Mental Illness: Reflections on Past Accomplishments and Directions for Future Research*

Over the past 40 years, the mental health care system has been radically transformed from one focused on institutionalized care to one centered on treatment in community settings. While medical sociology has played a prominent role in the study of psychiatric hospitalization and the deinstitutionalization process, the systematic exploration of the sociological dimensions of community-based mental health care is only just beginning. This essay reflects on past disciplinary contributions and explores some important empirical and theoretical directions in the field of mental illness research that could benefit from more extensive sociological analysis. The central argument is that the shift to a community-based mental health system has increased the need for the sociological perspective and that medical sociologists, in particular, have the theoretical and analytical perspective essential for developing a more complete understanding of the current conditions impacting the lives of people with severe mental disorders. Drawing on recent work in medical sociology, we illustrate some important topical areas at the center of controversies over treatment, social change, and public policy regarding severe mental illness. We conclude with a discussion of the barriers to this type of sociological research and suggestions for ways medical sociologists might contribute to the study of severe mental disorders in the future.

The Dawn Project: A model for responding to the needs of children with emotional and behavioral challenges and their families

Systems of care represent a fundamental departure from traditional service provision by espousing genuine family-centered, culturally competent philosophies and blending the funding streams of multiple payers (e.g., education, mental health, child welfare). In Marion County, Indiana, local leaders created a system of care based on these principles called the Dawn Project. Currently, a comprehensive, multidisciplinary evaluation is being implemented to evaluate the program. Preliminary findings from initial evaluation efforts suggest that for youth in the project, there is significant clinical improvement during the first year of receiving services, a reduction in the use of more restrictive settings, and a decrease in recidivism among those who successfully complete the program.

Relationship of Stigma to HIV Risk Among Women with Mental Illness

Urban women with severe mental illness (SMI) are vulnerable to stigma and discrimination related to mental illness and other stigmatized labels. Stigma experiences may increase their risk for negative health outcomes, such as HIV infection. This study tests the relationship between perceived stigma and HIV risk behaviors among women with SMI. The authors interviewed 92 women attending community mental health programs using the Stigma of Psychiatric Illness and Sexuality Among Women Questionnaire. There were significant relationships between personal experiences of mental illness and substance use accompanying sexual intercourse; perceived ethnic stigma and having a riskier partner type; and experiences of discrimination and having a casual or sex-exchange partner. Higher scores on relationship stigma were associated with a greater number of sexual risk behaviors. The findings underscore the importance of exploring how stigma attached to mental illness intersects with other stigmatized labels to produce unique configurations of HIV risk. HIV risk reduction interventions and prevention research should integrate attention to stigmatized identities in the lives of women with SMI.

Specifying the integration of mental health and primary health care services for persons with HIV/AIDS: The Indiana integration of care project

Abstract Most health care providers agree that the integration and coordination of primary and mental health care is critical for improving the continuity of care and the overall health status of people with HIV/AIDS. While some research examines programs designed to coordinate services for people living with HIV, very little research addresses the systems-level network integration of services in AIDS care. In this paper, a research-services demonstration program, the Indiana Integration of Care Project (IICP), is described. The program is intended to enhance the integration of mental health centers with the primary health-care sector for people living with HIV/AIDS in Indiana. A network theory of the structural factors influencing the patterns of integration between these sectors is offered. Drawing on baseline survey data, the current pattern of interorganizational network relationships of mental health centers with the AIDS care sector is described, and a preliminary examination of the theoretical framework guiding the IICP program is presented. The authors conclude with an overview of the planned systems-level network development intervention designed to enhance the ties between these service areas in the northeastern region of the state.

Perceived Mental Illness Stigma Among Youth in Psychiatric Outpatient Treatment

This research explores the experiences of mental illness stigma in 24 youth (58.3% male, 13-24 years, 75% Latino) in psychiatric outpatient treatment. Using Link and Phelan’s (2001) model of stigmatization, we conducted thematic analysis of the interview texts, examining experiences of stigma at individual and structural levels, in addition to the youths’ social-psychological processes. Youth in psychiatric treatment acknowledged that their larger cultural context holds pejorative viewpoints toward those with mental illness and reported experiences of stigma within their families and social networks. Our results also offer insight into the social-psychological processes of stigma, highlighting how labeling may influence their self-concept and the strategies in which youth engage to manage a stigmatized identity. We discuss differences in stigma experiences by gender, age, and diagnosis. Findings provide new information on the stigma experiences of youth in psychiatric treatment and suggest that a multilevel approach to reduce stigma is warranted.

Medical Sociology and Health Services Research Past Accomplishments and Future Policy Challenges

The rising costs and inconsistent quality of health care in the United States have raised significant questions among professionals, policy makers, and the public about the way health services are being delivered. For the past 50 years, medical sociologists have made significant contributions in improving our understanding of the nature and impact of the organizations that constitute our health care system. In this article, we discuss three central findings in the sociology of health services: (1) health services in the U.S. are unequally distributed, contributing to health inequalities across status groups; (2) social institutions reproduce health care inequalities by constraining and enabling the actions of health service organizations, health care providers, and consumers; and (3) the structure and dynamics of health care organizations shape the quality, effectiveness, and outcomes of health services for different groups and communities. We conclude with a discussion of the policy implications of these findings for future health care reform efforts.

The closing of central state hospital: Long-term outcomes for persons with severe mental illness

This study examined the clinical/community functioning of long-stay patients following closing of a large state psychiatric hospital. Two overlapping samples were followed: (1) the tracking project collected information on patient location, treatment provision, legal contacts, and level of functioning (LOF) and followed all discharged patients and (2) the research study subsample, drawn from the final group of discharged patients, gathered information on quality of life (QOL), LOF, and general physical and mental health. At follow-up, patients were functioning equal to or better than prior to discharge. There were consistent improvements in QOL (especially safety and occupational satisfaction) and LOF (especially housing and income/benefits). Fewer than 27% of patients discharged into the community were rehospitalized, and fewer than 4% were either in jail or homeless after 24 months. The study demonstrates that even persons who have been hospitalized for extremely long periods can do well in the community.